Do Surgeons Experience Moral Dissonance When There Is Misalignment Between Evidence and Action? A Survey and Scenario-based Study.

BACKGROUND: Moral dissonance is the psychological discomfort associated with a mismatch between our moral values and potentially immoral actions. For instance, to limit moral dissonance, surgeons must develop a rationale that the potential for benefit from performing surgery is meaningfully greater than the inherent harm of surgery. Moral dissonance can also occur when a patient or one's surgeon peers encourage surgery for a given problem, even when the evidence suggests limited or no benefit over other options. Clinicians may not realize the degree to which moral dissonance can be a source of diminished joy in practice. Uncovering potential sources of moral dissonance can help inform efforts to help clinicians enjoy their work. QUESTIONS/PURPOSES: In a scenario-based experiment performed in an online survey format, we exposed musculoskeletal specialists to various types of patient and practice stressors to measure their association with moral dissonance and asked: (1) What factors are associated with the level of pressure surgeons feel to act contrary to the best evidence? (2) What factors are associated with the likelihood of offering surgery? METHODS: We performed a scenario-based experiment by inviting members of the Science of Variation Group (SOVG; an international collaborative of musculoskeletal surgeons that studies variation in care) to complete an online survey with randomized elements. The use of experimental techniques such as randomization to measure factors associated with specific ratings makes participation rate less important than diversity of opinion within the sample. A total of 114 SOVG musculoskeletal surgeons participated, which represents the typical number of participants from a total of about 200 who tend to participate in at least one experiment per year. Among the 114 participants, 94% (107) were men, 49% (56) practiced in the United States, and 82% (94) supervised trainees. Participants viewed 12 scenarios of upper extremity fractures for which surgery is optional (discretionary) based on consensus and current best evidence. In addition to a representative age, the scenario included randomized patient and practice factors that we posit could be sources of moral distress based on author consensus. Patient factors included potential sources of pressure (such as "The patient is convinced they want a specific treatment and will go to a different surgeon if they don't get it") or experiences of collaboration (such as "The patient is collaborative and involved in decisions"). Practice factors included circumstances of financial or reputational pressure (such as "The practice is putting pressure on you to generate more revenue") and factors of limited pressure (such as "Your income is not tied to revenue"). For each scenario, the participant was asked to rate both of the following statements on a scale from 0 to 100 anchored with "I don't feel it at all" at 0, "I feel it moderately" at 50, and "I feel it strongly" at 100: (1) pressure to act contrary to best evidence and (2) likelihood of offering surgery. Additional explanatory variables included surgeon factors: gender, years in practice, region, subspecialty, supervision of trainees, and practice setting (academic/nonacademic). We sought factors associated with pressure to act contrary to evidence and likelihood of offering surgery, accounting for potential confounding variables in multilevel mixed-effects linear regression models. RESULTS: Accounting for potential confounding variables, greater pressure to act contrary to best evidence was moderately associated with greater patient despair (regression coefficient [RC] 6 [95% confidence interval 2 to 9]; p = 0.001) and stronger patient preference (RC 4 [95% CI 0 to 8]; p = 0.03). Lower pressure to act contrary to evidence was moderately associated with surgeon income independent of revenue (RC -6 [95% CI -9 to -4]; p < 0.001) and no financial benefit to operative treatment (RC -6 [95% CI -8 to -3]; p < 0.001). Marketing concerns were the only factor associated with greater likelihood of offering surgery (RC 6 [95% CI 0 to 11]; p = 0.04). CONCLUSION: In this scenario-based survey experiment, patient distress and strong preferences and surgeon financial incentives were associated with greater surgeon feelings of moral dissonance when considering discretionary fracture surgery. CLINICAL RELEVANCE: To support enjoyment of the practice of musculoskeletal surgery, we recommend that surgeons, surgery practices, and surgery professional associations be intentional in both anticipating and developing strategies to ameliorate potential sources of moral dissonance in daily practice.

Patient-Reported Outcome Measurement in Orthopaedic Trauma.

Patient-reported outcome (PRO) measurements are validated tools developed to quantify self-reported aspects of capability, mindset, and circumstances in a standardized fashion. While PRO measurements have primarily been used in the research realm, a growing body of work now underscores substantial opportunities in applying the data generated by these tools to advance patient-centered musculoskeletal care. Specifically, the insights into a patient's health status derived from these measures can augment the standard biomedical approach to the management of patients with orthopaedic trauma. For instance, PRO measures have demonstrated the high prevalence of psychological distress and social concerns within trauma populations and shown that mindsets and circumstances account for a substantial amount of the variation in levels of symptom intensity and capability in these patients. Such findings support the need for a more integrated, biopsychosocial, and multidisciplinary team-based approach to orthopaedic trauma care that include both technical and nontechnical skillsets. In this chapter, we explore the range of available fixed-scale and computer adaptive PRO measures that can quantify aspects of capability, mindsets, and circumstances of the patient with orthopaedic trauma during their experience of injury, recovery, and rehabilitation. Furthermore, we define human, technical, and system-level challenges within the often complex, dynamic, and clinically intense trauma setting. Finally, we highlight potential opportunities through successfully implementing PRO measurements for clinical decision support, shared decision making, predicting health outcomes, and developing advanced care pathways for patients and populations with orthopaedic trauma.

Cost Variation in Temporizing External Fixation of Tibial Plateau and Pilon Fractures: Is There Room to Improve?

INTRODUCTION: External fixator costs have been shown to be highly variable. Current information on external fixator costs and cost drivers is limited. The aim of this study was to examine the cost variation as well as the patient-, injury-, and surgeon-related cost drivers associated with temporizing external fixation constructs in tibial plateau and pilon fracture management. MATERIALS AND METHODS: A retrospective review was conducted to identify isolated tibial plateau and pilon fractures treated with temporizing external fixation from 2006-2018 at a level 1 trauma center. Inclusion criteria were based on fractures managed with primary external fixation, skeletal maturity, and isolated ipsilateral fracture fixation. Fracture patterns were identified radiographically using Schatzker, Weber, and OTA classification systems. Implant costs were determined using direct purchase price from the institution. The primary outcome was the external fixator total construct cost. Clinical covariates and secondary outcomes, namely unplanned reoperations, were extracted. Factors associated with cost (i.e. cost drivers) were identified via multivariable regression analysis. RESULTS: A total of 319 patients were included in this study (121 tibial plateau and 198 pilon fractures). Mean plateau construct cost was $5,372.12 and mean pilon construct cost was $3,938.97. Implant cost correlated poorly with demographic (r2=0.01 & r2=0.01), injury-independent (r2<0.01 & r2=0.03), and fracture pattern classifications (r2=0.03 & r2=0.02). Traumatologists produced significantly cheaper implants for pilon fractures (p=0.05) but not for plateau fractures (p=0.85). There was no difference in construct cost or components between patients that underwent unplanned reoperation and those that did not for both tibial plateau (p>0.19) and pilon (p>0.06). Clamps contributed to 69.9% and 77.3% of construct costs for tibial plateau and pilon, respectively. The most cost-efficient fixation constructs for tibial plateau and pilon fractures were the following respectively: of 5 clamps, 2 bars, and 4 pins; and of 4 clamps, 2 bars, and 3 pins. CONCLUSIONS: There is large cost variation in temporizing external fixation management. Cost drivers included surgeon bias and implant preference as well as use of external fixator clamps. Introducing construct standardization will contain healthcare spending without sacrificing patient outcomes. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.

Measurement of value in rotator cuff repair: patient-level value analysis for the 1-year episode of care.

BACKGROUND: Rotator cuff repair (RCR) is one of the most common elective orthopedic procedures, with predictable indications, techniques, and outcomes. As a result, this surgical procedure is an ideal choice for studying value. The purpose of this study was to perform patient-level value analysis (PLVA) within the setting of RCR over the 1-year episode of care. METHODS: Included patients (N = 396) underwent RCR between 2009 and 2016 at a single outpatient orthopedic surgery center. The episode of care was defined as 1-year following surgery. The Western Ontario Rotator Cuff index was collected at both the initial preoperative baseline assessment and the 1-year postoperative mark. The total cost of care was determined using time-driven activity-based costing (TDABC). Both PLVA and provider-level value analysis were performed. RESULTS: The average TDABC cost of care was derived at $5413.78 ± $727.41 (95% confidence interval, $5341.92-$5485.64). At the patient level, arthroscopic isolated supraspinatus tears yielded the highest value coefficient (0.82; analysis-of-variance F test, P = .01). There was a poor correlation between the change in the 1-year Western Ontario Rotator Cuff score and the TDABC cost of care (r2 = 0.03). Provider-level value analysis demonstrated significant variation between the 8 providers evaluated (P < .01). CONCLUSION: RCR is one of the most common orthopedic procedures, yet the correlations between cost of care and patient outcomes are unknown. PLVA quantifies the ratio of functional improvement to the TDABC-estimated cost of care at the patient level. This is the first study to apply PLVA over the first-year episode of care. With health care transitioning toward value-based delivery, PLVA offers a quantitative tool to measure the value of individual patient care delivery over the entire episode of care.

Can Reducing Implant Costs Increase Revenue for Surgically Treated Ankle Fractures: Time-Driven Activity-Based Costing for 1-Year Episode of Care.

BACKGROUND: The purpose of this study was to investigate whether decision-making regarding implant selection affects the reimbursement margins for the surgical fixation of ankle fractures. METHODS: All ankle fractures treated between 2010 and 2017 within a single-insurer database were identified via Current Procedural Terminology codes by review of electronic medical record. Implant cost was determined via the implant record cross-referenced with the single contract institutional charge master database. The Time-Driven Activity-Based Costing (TDABC) technique was used to determine the costs of care during all activities throughout the 1-year episode of care. Statistical analysis consisted of multiple linear regression and goodness-of-fit analyses. RESULTS: In all, 249 patients met inclusion criteria. Implant costs ranged from $173 to $3944, averaging $1342 ± $751. The TDABC-estimated cost of care ranged from $1416 to $9185, averaging $3869 ± $1384. Finally, the total reimbursed cost of care ranged between $1335 and $65 645, averaging $13 954 ± $9445. The implant costs occupied an estimated 34.7% of the TDABC-estimated cost of care per surgical encounter. Implant cost, as a percentage of the overall TDABC, was estimated as 36.2% in the inpatient setting and 33% in the outpatient setting, which was the second highest percentage behind surgical costs in both settings. We found a significant increase in net revenue of $1.93 for each dollar saved on implants in the outpatient setting, whereas the increase in net revenue per dollar saved of $1.03 approached significance in the inpatient setting. CONCLUSION: There is a direct relationship between intraoperative decision-making, as evidenced by implant choices, and the revenue generated by surgical fixation of ankle fractures. Intraoperative decision-making that is cognitive of implant cost can facilitate adoption of institutional cost containment measures and prompt increased healthcare value. LEVEL OF EVIDENCE: Level III: Retrospective cohort study.